Dear Ms. DID: Regarding a dissociative episode and diagnoses vs Bipolar III and PTSD

Question:

Is it very common for someone with retraumitized PTSD with a recent dissociative episode (connected w/the retraumitization) to be diagnosed with Bipolar III Disorder instead of PTSD? If you know of any studies discerning one from another, please let me know. Thank you.
Best wishes,

Karen


Dear Karen,

Your question is something I have very little knowledge of. I have heard of misdiagnoses between Biopolar and DID, but I had to read up a little myself, since I do experience dissociative episodes rather frequently. I am also not sure if you mean the individual was previously diagnosed with PTSD, and then rediagnosed with bipolar III after the dissociative episode.

Unfortunately, I can find no direct research, but did in a roundabout way sort of conclude, in a very layman’s way, that these two conditions are only loosely-related and I wonder how one could be mis-diagnosed as the other, unless a clinician feels that both are present. (Include tons of standard disclaimers here about me not being a clinician, etc.)

But first, let’s define some conditions.

There are several classifications of Bipolar disorder – the DSM-IV lists three, although researchers have added more based on finer slicing of symptoms. It appears that bipolar is moving to a spectrum rather than a few specific classifiers, perhaps as dissociation exists along a spectrum from normal dissociation through polyfragmented DID. But according to the DSM-IV, all three (Bipolar III, dissociation, and PTSD) are in different categories (mood disorders, dissociative disorders, and anxiety disorders, respectively).

Bipolar quick overview:

Bipolar disorder is considered a mood disorder (DSM-IV). Also, see the Bipolar FAQ here and a comprehensive site at www.pendulum.org.

* Bipolar Disorder I – Manic and mixed episodes that tend to interfere with ability to engage in daily life activities. Cycles with major depression. Most severe form.
* Bipolar Disorder II – Hypomanic (less severe than manic) episodes without hallucinations or paranoia. Major depression still present.
* Bipolar Disorder III – aka Cyclothymic Disorder – less severe form including cycling hypomania and depressive episodes that are not as severe as in I and II.

One researcher’s expanded shorthand: Young and Klerman Subtypes

* Bipolar I – Mania and Major Depression
* Bipolar II – Hypomania and Major Depression
* Bipolar III – Cyclothymia
* Bipolar IV – Antidepressant Induced Hypo/mania
* Bipolar V – Major Depression with a family history of Bipolar Disorder
* Bipolar VI – Unipolar Mania

What is PTSD?

PTSD is considered an anxiety disorder (DSM-IV). Just an overview – an anxiety disorder caused by extreme stress such as wartime exposure, sexual assault, natural disaster, etc., where the individual felt that their life was in danger. Symptoms include periods of numbness, hyperarousal, bursts of anger, easy to startle, seem to overreact to “normal” situations, flashbacks of the situation. [PTSD fact sheet]

What is retraumatized PTSD?

I found three descriptions:

1) “Women sexually assaulted in both childhood and adulthood” who were “alexithymic, show dissociation scores indicating risk for dissociative disorders, and to have attempted suicide compared to the other two groups”. [Cloitre] Alexithmia is a difficulty understanding, processing, or describing emotions. No words for mood; difficulty expressing.

2) Repeated trauma (e.g., continuing abusive situation; multiple tours of military duty)

3) Forcing people to recall and/or relive traumatic memories before they are ready to address them.

What is a dissociative episode?

Dissociation is the feeling that you are not yourself, or that you are disconnected from the world. It can be associated with amnesia of periods of time, ending up in a place you don’t remember going to, and in extreme cases, feeling as several different selves who may or may not be aware of the others. During an episode, the individual may feel detached from a situation, sometimes to relieve pain associated with a situation. Feeling numb or spaced out is also common.

Dissociation is considered a dissociative disorder (DSM-IV).

Diagnosis of Bipolar III rather than PTSD

Karen asks of an individual with retraumatized PTSD can be diagnosed with Bipolar III after a dissociative episode.

First, dissociation associated with any type of PTSD is not a stretch. For retraumatization, it is very likely. The question is if this can be extended to Bipolar III.

This website discusses diagnostic criteria for Bipolar I and II (not III); but the differential diagnosis (other conditions with some overlapping symptoms that clinicians must rule out to make a diagnosis) for neither includes PTSD or dissociation. This seems to imply that, for more severe forms of bipolar, that the symptoms do not overlap enough to be confused with dissociation caused by retraumatization PTSD.

However, with trauma, PTSD sometimes is associated with dissociative disorders. And, dissociative disorders have classically, and are still, misdiagnosed. Common misdiagnoses include schizophrenia and bipolar disorder. So, it could be possible for such a mis-diagnosis to occur since the differential diagnosis of these are loosely related. For example, differential diagnosis for bipolar I and II includes schizophrenia, which includes in its differential diagnosis, severe dissociation. Kinda like the geometry proof: if A = B, and B=C, then A = C.

These are a little roundabout. Here is another loose example. PTSD is often associated with dissociative disorders – with sexual assault (especially repeated), the most common diagnosis is PTSD/DDNOS (dissociative disorder not otherwise specified). Also, PTSD/DID dual diagnoses are common. In each, an individual may behave in different ways over time due to dissociation; in the extreme case, multiple personalities. Often there are very happy ones who are unaware of the trauma, and very depressed ones that are aware of the trauma. Now, bipolar disorder III is associated with highs and lows that do not swing as radically as bipolar I or II.

In the case Karen proposes, I SUPPOSE it is possible that a new dissociative episode associated with the retraumatization COULD be misconstrued as the mood cycling of bipolar III.

I would suggest that the dissociative episode be explored more fully to see what triggered it and why it occurred. There are so many reasons for individuals with PTSD to be triggered that this seems more logical than bipolar III if the dissociation only happened once, and happened after a known retraumatization.

Some related stuff

During my digging, I found some related stuff that doesn’t quite answer these questions, but does provide data and references relating Borderline Personality Disorder (BPD) to several conditions such as PTSD, dissociation, and schizophrenia. The co-incidence of these is not unusual. The relevance is questionable, as BPD is considered a personality disorder in the DSM-IV rather than bipolar disorder, which is classified as a mood disorder. [Tortosa] However, I have seen it suggested that BPD lies within the bipolar spectrum – a good article is here. [ePsychology]

Conclusion

I am sorry to say that I don’t know the answer, and I can find no concrete information that may help. I suppose the mis-diagnosis could occur, but the best thing is to explore it more fully with a therapist who is versed in all three conditions.

References

Cloitre M et al., (1997). Posttraumatic stress disorder, self- and interpersonal dysfunction among sexually retraumatized women, Journal of traumatic stress, 1997, vol. 10, no3, pp. 437-452 (1 p.3/4)April 2004

Department of Veteren’s Affairs. (2007). Fact Sheet. What is Posttraumatic Stress Disorder (PTSD)?, accessed from http://www.ncptsd.va.gov/ncmain/ncdocs/fact_shts/fs_what_is_ptsd.html

ePsychology.us (???). Borderline Personality Disorder, accessed from http://www.epsychology.us/borderline-personality-disorder/

Pueschel M. (2004) PTSD Prevention, Care Techniques Debated, US Medicine, accessed from http://www.usmedicine.com/article.cfm?articleID=842&issueID=61

Tortosa A. (2007). Summary of borderline personality disorder , AAPEL, accessed from http://www.aapel.org/bdp/BLsyntheseUS.html

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7 Comments»

  Karen wrote @

Hi Emily,

That is an amazingly knowledgable and critical article. Thank you so much!

Have a good weekend,

Karen

[…] [Link] […]

  Shasta wrote @

Another facet to this issue is the fact that people with identifiable Bipolar Disorder were generally more abused as children than the general population. I had thought this for a long time. I have bipolar myself and it seemed a number of those in our support groups had been abused. Now there is some data. It makes sense. Bipolar Disorder is genetic. When one parent has it, their children have a one in five chance of getting it too. Think about the emotional turmoil and abuse that goes on in families where a parent, grandparent, or a child all have forms of bipolar. The other factor is that people with Bipolar have lower resilence as children making it more likely that a painful event will be elevated to the level of trauma. Bipolar, PTSD, borderline, DID manifest differently but it is not at all uncommon that they should occur together. I am saying this from the standpoint of one who has both Bipolar and DDNOS

  Emily’s Camigwen wrote @

It seems to me anything in the realm of mental health illness in parents and/or children can just wreak havoc through all phases of life. When I started this journey, I was pretty blind to all this. Learning all this is enlightening from an intellectual viewpoint (which is also a good reason I do it) but completely depressing from an emotional viewpoint.

Thanks for sharing your thoughts.

  davidrochester wrote @

My answer to this question would be “yes” — from personal experience. I resisted the diagnosis, and am very glad I did. I displayed what *looked* like cyclical hypomania, but which was actually repeated PTSD triggers that would cause me to act in a highly energetic, agitated way, repeatedly, as the stimulus causing the behavior kept occurring on a regular basis.

The differentiating factor, IMO, between actual hypomania and a trauma trigger, is whether the mania extends to all facets of the person’s life, or is situation-specific. The therapist who pegged me as Bipolar III never asked this question. My current therapist, who diagnosed me with DID, asked the question.

  Emily’s Camigwen wrote @

The idea of situation-specific mania…so help me with this. A few times in my life I have “come up for air” and allowed myself to really wonder what the hell was wrong with me. The last time was around 2001 and I suspected bipolar – it seems a very common mistake, if that is the word.

The depression is obvious, but the “manias” that made me suspect biploar sometimes came from nowhere but I am sure were triggered somehow. Then I would find childlike wonder bubble out of me and dance in the hall. The excitement of something made me act “too” happy. And I see now are clearly associated with a few parts of me, but I am not sure what you mean by situation specific?

I won an award and was very happy and proud – but clapping my hands like a 5 year old with a big grin…is that situation specific? Or, do you mean “always manic with cooking in the kitchen”?

  davidrochester wrote @

That doesn’t sound to me like classic mania, or even hypomania … it sounds more like the spontaneous happiness of a kid. 🙂 Mania has the curious feature of feeling completely different to the person experiencing it than it looks to outsiders … it feels like a highly productive, euphoric and positive energy surge, and looks like hyperactive or irrational behavior to people observing … the person suffering the mania often feels very powerful and in control, and sometimes they are very compelling and exciting when in that state of mind, but it’s common for people watching someone in a manic or hypomanic state to perceive that person as obsessive or “out of control.”

I’m trying to think of a good simple example … I am most frequently triggered into this state when I am given a project with a deadline. In fact, now that I think about it, I am always triggered into that state; I rev into a very high gear and become intensely focused and energetic in a way that is neither normal nor particularly helpful to what I’m doing. People watching me are often amazed at how much I get done, and also make repeated suggestions that I slow down, for the sake of my own sanity. This is not normal bipolar mania; it is not cyclical at all. I had an episode of this earlier this year, when I was given a writing project with a tight deadline, but prior to that, I hadn’t been in that state of mind for more than a year.

The obvious trigger for me is to be given an expectation that I’m not sure I can meet, since so much of my sense of value is held in my ability to perform appropriately.


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